Ann Hepatobiliary Pancreat Surg.  2020 Nov;24(4):445-453. 10.14701/ahbps.2020.24.4.445.

Portal vein reconstruction using side-to-side unification technique for infant-to-infant deceased donor whole liver transplantation

• Namgoong JM
• Hwang S
• Ahn CS
• Kim KM
• Oh SH
• Kim DY
• Ha TY
• Song GW
• Jung DH
• Park GC

• KMID: 2508853
• DOI: http://doi.org/10.14701/ahbps.2020.24.4.445

Abstract

Backgrounds/Aims
Infant-to-infant whole liver transplantation (I2I-WLT) has been rarely performed in Korea. We analyze clinical sequences of our 7 cases of I2I-WLT and present evolution of surgical techniques to prevent PV stenosis.
Methods
A total of 7 cases of I2I-WLT were performed at our institution during last 13 years, which represented 0.1% of our LT volume. Patient perioperative profiles and clinical sequences were analyzed with focusing on portal vein (PV) complications.
Results
Donor ages were 6-17 months and graft weights were 140-525 g. Recipient ages were 7-16 months and body weights were 6-10.1 kg and Primary diagnoses were biliary atresia in 6 and progressive familial intrahepatic cholestasis in 1. The first case underwent PV stenting 2 months after I2I-WLT, and underwent retransplantation 6 years later. The second case underwent intraoperative PV stenting, but died 32 days later. The third case underwent repeated PV dilatation. The fourth, fifth and seventh cases experienced no surgical complications, and PV reconstruction was performed using a side-to-side unification venoplasty technique. The sixth case had poor development of the PV system, so customized PV venoplasty was performed, but PV occlusion requiring PV stenting occurred. Early retransplantation was performed, but scanty PV flow was detected despite no obvious PV stenosis, resulting in graft failure. Serious PV complications developed in 4, but none experienced after adoption of side-to-side unification venoplasty.
Conclusions
As PV size in infant donors and recipients is very small, PV reconstruction in I2I-WLT requires specialized surgical techniques of side-to-side unification venoplasty.

Keyword

Complication; Portal vein; Pediatric transplantation; Deceased donor; Venoplasty

Figure

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  Fig. 1 Illustration of the side-to-side unification technique used for portal vein (PV) reconstruction. A deep longitudinal incision was made at the “6 o’clock” direction of the graft PV and the “12 o’clock” direction of the recipient PV. Running sutures were then used to unify these two PVs. This technique creates an enlarged conduit from the superior mesenteric vein-splenic vein confluence to the hilar PV confluence.

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  Fig. 2 Kaplan-Meier curves of the graft (A) and patient (B) survival.

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  Fig. 3 Clinical sequence of Case No. 1. Computed tomography (CT) images taken preoperation (A) and at day 2 posttransplant (B) showing the sequence of the compression-induced liver infarct. PV anastomotic stenosis (C) was detected and a wall stent was inserted 2 months later. After 6 years, the liver graft failed (D and E) and retransplantation was performed (F).

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  Fig. 4 Clinical sequence of Case No. 2. A preoperative CT scan showed the underdevelopment of the PV (A). Intraoperative PV stenting was performed because of weak PV flow (B). A dynamic CT scan showed reduced perfusion of the liver parenchyma (C and D).

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  Fig. 5 Clinical sequence of Case No. 3. CT images taken preoperation (A) and at day 7 posttransplant (B) showing the sequence of the PV stenosis. Percutaneous balloon dilatation was repeatedly performed at 2 (C), 6 (D), and 16 months (E).

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  Fig. 6 Imaging findings of PV reconstruction using the side-to-side unification technique. A comparison of CT images taken preoperation (A) and at day 7 posttransplant (B) showed no evidence of PV complication in Case No. 4. Intraoperative imaging showed the completed PV reconstruction prior to portal reperfusion (C) in Case No. 5, which resulted in smooth streamlined PV reconstruction as assessed by day 7 CT angiography (D).

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  Fig. 7 Clinical sequence of Case No. 6. Preoperative CT angiography (A) revealed marked hypoplasia of the PV (arrow). PV stenting was performed at day 1 because of PV occlusion (B). A direct portogram was also performed during retransplantation, in which potential collateral veins were embolized with multiple coils (C). The liver perfusion status of this patient was poor after retransplantation on day 14, as revealed by CT (D) and Doppler ultrasonography (E).

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  Fig. 8 Imaging findings of PV reconstruction using the side-to- side unification technique in Case No. 7. The ventral surface of the whole liver graft was visible with closure of the inferior stump of the vena cava (A). The recipient PV was hypolastic (arrow) (B). Redundant PV reconstruction with side-to-side unification technique was shown to avoid compression by the caudate lobe (C). Dynamic CT portography taken at 1 year showed normal configuration of the PV anastomosis.

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